Provider Demographics
NPI:1437913159
Name:NOEL-BELASCO, THERESA J
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:J
Last Name:NOEL-BELASCO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1260 ISLAND AVE NW
Mailing Address - Street 2:
Mailing Address - City:PALM BAY
Mailing Address - State:FL
Mailing Address - Zip Code:32907-7851
Mailing Address - Country:US
Mailing Address - Phone:321-446-1967
Mailing Address - Fax:
Practice Address - Street 1:1260 ISLAND AVE NW
Practice Address - Street 2:
Practice Address - City:PALM BAY
Practice Address - State:FL
Practice Address - Zip Code:32907-7851
Practice Address - Country:US
Practice Address - Phone:321-446-1967
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-13
Last Update Date:2024-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11031226363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily